Ebook Atlas of mammography (3/E): Part 1

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Atlas of
Mammography
THIRD EDITION

ELLEN SHAW de PAREDES, MD, FACR
Founder and Director
Ellen Shaw de Paredes Institute for Women’s Imaging
Glen Allen, Virginia
Clinical Professor of Radiology
University of Virginia
School of Medicine
Charlottesville, Virginia
Clinical Professor of Medicine
Virginia Commonwealth University
Richmond, Virginia


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© 2007 by LIPPINCOTT WILLIAMS & WILKINS, a Wolters Kluwer business
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All rights reserved. This book is protected by copyright. No part of this book may be reproduced
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Printed in the United States of America
Library of Congress Cataloging-in-Publication Data
de Paredes, Ellen Shaw.
Atlas of mammography / Ellen Shaw de Paredes.—3rd ed.
p. ; cm.
Rev. ed. of: Atlas of film-screen mammography. 2nd ed. c1992.
Includes bibliographical references and index.
ISBN-13: 978-0-7817-6433-9
ISBN-10: 0-7817-6433-5
1. Breast—Cancer—Diagnosis—Atlases. 2. Breast—Radiography—Atlases.
I. de Paredes, Ellen Shaw. Atlas of film-screen mammography. II. Title.
[DNLM: 1. Breast Neoplasms—radiography—Atlases. 2. Mammography—Atlases.
WP 17 D278a 2007]
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To Victor, for his tremendous encouragement, support, advice, and dedication.
and
To my parents, George and Julia Shaw, who inspired me to achieve my goals.
I am forever grateful.


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CONTENTS

Preface to the Third Edition vii
Preface to the First Edition ix
Foreword from the Second Edition xi

1 Anatomy of the Breast 1
2 Techniques and Positioning in
Mammography 18

3 An Approach to Mammographic
Analysis 61

4
5
6
7
8

Circumscribed Masses 104
Indistinct and Spiculated Masses 186
Analysis of Calcifications 238
Prominent Ductal Patterns 339
Asymmetry and Architectural
Distortion 363

10
11
12

13
14
15
16
17

The Axilla 445
The Male Breast 470
The Postsurgical Breast 482
The Augmented Breast 528
Galactography 567
Needle Localization 584
Percutaneous Breast Biopsy 602
The Roles of Ultrasound and Magnetic
Resonance Imaging in Breast Imaging 633

Index 671

9 The Thickened Skin Pattern 418

v


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PREFACE to the THIRD EDITION

“The heights by great men reached and kept
Were not attained by sudden flight
But they, while their companions slept
Were toiling upward in the night”
—Longfellow

M

ammography is a well established technique that
has been proven to reduce the death rate for breast cancer
in screened populations of women. Since the last edition
of this book, major changes have occurred in breast imaging. Mammography has been well established and is utilized as a screening and diagnostic tool. Breast ultrasound
and MRI are also used frequently in the evaluation of
abnormalities. Breast interventional procedures are more
varied and serve to diagnose breast lesions. Digital mammography has been developed, approved by the Food and
Drug Administration and is utilized in the United States
and abroad. The Mammography Quality Standards Act
was passed by Congress and implemented, and is an
important mechanism for standardizing and improving
the quality of mammography services. The training of
radiologists in breast imaging is now a well established
component of radiology residency programs. Even with
improved techniques, tools and training, the challenge for
the radiologist remains to identify breast cancer when it is
small and curable.
The focus of this book is to present via mammographic
images, the patterns of normal and abnormal breasts so
that radiologists may be better equipped to identify breast
cancers. The Atlas of Mammography serves as a primary
training tool as well as a reference source when one is

faced with a diagnostic dilemma. The book is organized
based on a pattern-recognition format, thereby facilitating its use as a reference source.
Chapters on anatomy, techniques and positioning and an
approach to mammographic analysis are once again
included as well as a series of chapters on masses, calcifications, dilated ducts, the edema pattern and asymmetries.
The male breast, the axilla, the post surgical and augmented
breast are covered as well as a series of chapters on breast
interventions and the roles of ultrasound and MRI. New
chapters in this book are those on asymmetries and distortions, the augmented breast, galactography, needle localization, percutaneous breast biopsy, ultrasound and MRI. In

each chapter, comprehensive differential diagnoses are presented with cases demonstrating the various entities.
Images were acquired on Siemens analog and full field
digital units. All mammographic images are presented
with the patient’s left to the reader’s left. I prefer to read
film screen images in this orientation so that the surface
glare from the non emulsion side of the film is reduced.
There are many individuals I wish to thank for their
contributions to this book. First, my technologists, Diane
Loudermilk, Chrystal Sullivan, Robyn Ost, Deborah
Smith, and Lanea Bare are responsible for the excellent
radiography that served as the source material for this
book. Dr. Ami Trivedi was instrumental in case collection
and organization. Image production and graphics were
carefully prepared by Whitney Shank and who was
assisted by Mariel Santos. The photographs were prepared by Carlos Chavez. The editorial assistance provided
by my mother, Julia Shaw was invaluable. The pathology
images were provided by Dr. Michael Kornstein to whom
I am most thankful. Some of the unusual cases were provided by former fellows including Drs. Neeti Goel,
Thomas Poulton, Thomas Langer, Deanna Lane, Patricia
Abbitt, and Lindsay Cheng.

I gratefully thank my secretary, Ms. Louise Logan who
tirelessly worked on the manuscript preparation, giving
attention to all the details. I also thank Kerry Barrett at
Lippincott Williams & Wilkins for her editorial assistance.
The Ellen Shaw de Paredes Research Foundation provided support through a grant for book production and
preparation of materials, and I am most grateful for the
unwavering support of the Board.
Several individuals who are extremely important to me
helped to guide my career into the subspecialty of breast
imaging, a field that has so much meaning and importance
in improving patients’ lives. My parents, George and Julia
Shaw, encouraged me to be a physician and taught me the
value of education and the importance of self discipline.
My selection of the field of radiology was suggested by my
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viii

Preface to the Third Edition

husband, Dr. Victor Paredes, who encouraged me to write
the first Atlas and has been incredibly supportive and
encouraging of this endeavor. I thank Dr. Theodore Keats,
who was the first radiology chair under whom I worked, and
who directed me into breast imaging, giving me the opportunity to develop the section at the University of Virginia.
As I write this preface, I reflect on the many nights that
I sat up late until the early morning hours, working on the

book. As life has become busier with clinical work, the
effort to produce this book has been far greater than that
for the earlier editions. This effort was energized by the

kind support and constant encouragement of my husband, the loyalty of my dear dog Sam, who warmed my
feet as I wrote every word, and the powerful self discipline
that my mother has taught me. But most importantly so
many of my former residents and fellows have taught me
how much their training in mammography and their
knowledge has changed their own patients’ lives. I hope
that this work will provide the reader with greater insight
into the complexities of mammography.
Ellen Shaw de Paredes, M.D.


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P R E FA C E t o t h e F I R S T E D I T I O N

“People see only what they are prepared to see.”
(Ralph Waldo Emerson, Journals, 1863)

T

he early detection of breast cancer depends primarily
on mammography. With the increasing emphasis on
screening mammography by organizations such as the
American Cancer Society, there is rapidly expanding utilization of mammography services, and there is a concomitant need for increased training of radiologists and
radiology residents.
High-quality images are absolutely necessary for the

detection of subtle abnormalities. There are tremendous
differences in patterns of the breast parenchyma among
women. Although the number of diseases that affect the
breast is not vast, the perception and analysis of an
abnormality can make mammography seem difficult.
The purpose of this book is to present through images
the various manifestations of breast diseases, so that the
reader may use it not only as a reference source, but also
as a tool for developing pattern recognition skills in mammography. The book will be useful to practicing radiologists or to radiology residents in the process of learning
mammography.
Each chapter is introduced with a brief review of the
various processes that are manifested as a specific pattern,
and is followed by a series of radiographs demonstrating
the lesions. Correlation of clinical findings, mammographic findings, and histologic diagnosis is made. In
some cases, not only mammography but also ultrasound
images and histopathologic sections are correlated.
The initial sections discuss the anatomy and physiology of the breast, the proper techniques for performing
film-screen mammography, and the analysis of a mammogram. The body of the text deals with chapters divided by
patterns—well-defined masses, ill-defined masses, calcifications, prominent ducts, and thickened skin. The
remainder of the text covers the axilla, the male breast,
and interventional procedures in mammography.
The recent technical trends are towards film-screen
mammography. This book covers only film-screen tech-

niques, and all images are film radiographs. The images
were produced almost entirely at the University of
Virginia on either an Elscint Mam-II unit, which does not
utilize a grid, or newer Siemens Mammomat B and the
Mammomat-2 units with grids. The higher contrast and
improved image quality on the radiographs from the

equipment with grids are apparent on the reproductions.
Film-screen systems that have been utilized are Kodak
Ortho M film and Min-R screens and Kodak T-Mat M film
with Min-R Fast screens.
I wish to acknowledge the fine work of my dedicated
technologists. Deborah Smith, Diane Loudermilk, Mary
Owens, Bonnie Mallan, Marie Bickers, Theresa Breeden,
and Lisa Elgin, who are responsible for the radiographs.
My special thanks go to Deborah Smith for assisting in
writing the section on patient positioning. Manuscript
preparation was carried out by Joy Bottomly and Patsie
Cutright. Esther Spears, Catherine Payne, Kim Nash,
Adair Crawford, Susan Bywaters, Tracy Bowles, and Lisa
Crickenberger assisted in the collection of cases and other
production work. The line drawings were produced by
Craig Harding, and the reproductions of radiographs were
done by Ursula Bunch, Connie Gardner, and Patricia Pugh
of the Biomedical Communications Division. I wish to
thank Dr. Sana Tabbarah for her assistance with the
pathology slides and descriptions. My postresidency fellows, Drs. Patricia Abbitt and Thomas Langer, have
assisted greatly with clinical work, leaving me time to
work on this project. My appreciation also goes to other
physicians who have sent me interesting cases: Drs.
Luisa Marsteller, George Oliff, Jay Levine, Alexander
Girevendulis, A.C. Wagner, Bernard Savage, M.C. Wilhelm,
Melvin Vinik, and James Lynde. Lastly, I wish to thank my
husband, Dr. Victor Paredes, for his assistance with the
production and editing of the book. Without their help,
this work would not have been possible.
Ellen Shaw de Paredes, M.D.

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FOREWORD from the SECOND EDITION

A

lthough many years of effort have been spent in
improving surgical and radiotherapeutic techniques, the
mortality rate from breast cancer remains appalling. It is
commonly conceded that early detection is the best means
of reducing this mortality. Fortunately, mammography
has finally evolved as a means of achieving this purpose.
At last we have an opportunity to improve significantly the
cure rate for patients with breast cancer.
Mammography today is far different from what it was
when I became involved with it more than 25 years ago.
Progress has resulted from the dedicated efforts of the pioneers in this field, such as Egan and Wolfe and their associates. Today, this progress continues with further improvement in image quality, techniques for localizing lesions,
and biopsy procedures. These advances have led to greatly
improved detection rates. They have also made it necessary
for the radiologist constantly to modify his or her patterns
of practice and to become a perennial student in the field.

Dr. Ellen Shaw de Paredes has been tireless in the pursuit of excellence in her mammographic program at the
University of Virginia. Her work exemplifies the enlightened state of modern mammography. This book reflects
her clinical experience and contains a wealth of teaching

axioms gleaned from working with many residents, fellows, and surgical colleagues. Her new edition includes
additional case material to amplify her teaching points.
Also included are discussions of interventional procedures and a valuable chapter on the postoperative breast.
These additions should further enhance the scope of this
valuable work.
Theodore E. Keats, M.D.
Professor and Chairman
Department of Radiology
University of Virginia School of Medicine
Charlottesville, Virginia


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C h a p t e r

1

◗ Anatomy of the Breast
The breast or mammary gland is a modified sweat gland
that has the specific function of milk production. An
understanding of the basic anatomy, physiology, and histology is important in the interpretation of mammography. With an understanding of the normal breast, one is
better able to correlate radiologic-pathologic entities.

DEVELOPMENT
The development of the breast begins in the fifth-week
embryo with the formation of the primitive milk streak

from axilla to groin. The band develops into the mammary
ridge in the thoracic area and regresses elsewhere.
If there is incomplete regression or dispersion of the
milk streak, there is accessory mammary tissue present in
the adult, which occurs in 2% to 6% of women (1).
Accessory breast tissue, particularly in the axillary area,
that is separate from the bulk of the parenchyma may be
identified on mammography in these women (2) (Fig. 1.1).
The orientation of the milk streak is slightly lateral to the
nipple above the nipple line and medial to the nipple
below the nipple line. Therefore, patients with accessory
breasts, accessory parenchyma, or accessory nipples are
found to have these in the axillary region or just medial to
the nipple in the inferior aspect of the breast or upper
abdominal wall (Figs. 1.2, 1.3). In women with accessory
breast tissue, changes occur cyclically and with pregnancy
and lactation, as they do within the breasts themselves.
Therefore, these patients may note that areas of accessory
breast tissue may enlarge with pregnancy and may produce milk when the patient is lactating if there is a duct
orifice or nipple present.
At 7 to 8 weeks of embryologic development, there is
an invagination into the mesenchyma of the chest wall.
Mesenchymal cells differentiate into the smooth muscle
of the nipple and areola (1,3). At 16 weeks, epithelial buds
develop and branch. Between 20 and 32 weeks, placental
sex hormones entering the fetal circulation induce canalization of the epithelial buds to form the mammary ducts.

At 32 to 40 weeks, differentiation of the parenchyma
occurs, with the formation of the lobules (3,4).
The mammary gland mass increases by fourfold, and

the nipple-areolar complex develops (1). Developmental
anomalies include polymastia (accessory breasts along
the milk streak), polythelia (accessory nipples), hypoplasia of the breast (Fig. 1.4), amastia (absence of the breast),
and amazia (absence of breast parenchyma) (Fig. 1.5) (1).
Systemic or iatrogenic influences in childhood may be
related to breast hypoplasia or amazia. Iatrogenic causes
of amazia include excision of the breast bud during biopsy
of the prepubertal breast and the use of radiation therapy
to the chest wall during childhood (1) (Fig. 1.6).
During puberty in girls, the release of follicle-stimulating
hormone and luteinizing hormone by the pituitary causes
release of estrogens by the ovary. Hormonal stimulation
induces growth and maturation of the breasts. In early adolescence, the estrogen synthesis by the ovary predominates
over progesterone synthesis. The physiologic effect of estrogen on the developing breast is to stimulate longitudinal ductal growth and the formation of terminal ductule buds (1).
Periductal connective tissue and fat deposition increase (1),
accounting for increase in size and density of the breasts.

STRUCTURE
The adult breast is composed of three basic structures: the
skin, the subcutaneous fat, and the breast tissue, which
includes the parenchyma and the stroma. Beneath the
breast is the pectoralis major muscle, which is also
imaged during mammography. The breast parenchyma is
enveloped by deep and superficial fascial layers; Cooper’s
ligaments, the fibrous strands that support the breasts,
traverse the parenchyma and attach to the fascial layers.
The parenchyma is divided into 15 to 20 segments, with
each drained by a lactiferous duct (Fig. 1.7). The lactiferous ducts converge beneath the nipple, with about 5 to 10
major ducts draining into the nipple. Each duct drains a
lobe composed of 20 to 40 lobules (Fig. 1.8).

1


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Atlas of Mammography

Figure 1.1
HISTORY: A 30-year-old woman in

A.

B.

The microanatomy of the breast was described by
Parks in 1959 (4). Each lobule is 1 to 2 mm in diameter
and contains a complex system of tiny ducts (the ductules), which terminate in blind endings. The ductules can
respond to hormonal stimulation of pregnancy by proliferation and formation of alveoli (3). Two types of stroma
are present: the perilobular connective tissue, which contains collagen and fat, and the intralobular connective tissue, which does not contain fat (4).
Wellings et al. (5) further classified the microstructure
of the normal breast into the terminal duct lobular unit
(TDLU) (Fig 1.9). Small branches of the lactiferous ducts
lead into terminal ducts that drain a single lobule. The terminal duct is composed of the extralobular segment and
the intralobular segment. The lobule is composed of the
intralobular terminal duct and the blindly ending ductules
(5). The ductules are lined by a single layer of epithelial
cells and a flattened peripheral layer of myoepithelial cells

(5). A loose fibrous connective tissue stroma supports the
ductules of the lobule.
The TDLU is a hormone-sensitive gland varying from
1 to 8 mm in diameter in the nonpregnant state and having the potential of milk production (6). The lobules normally regress at menopause, leaving blunt terminal
ducts; however, in women older than 55 years with

the 32nd week of pregnancy,
presenting with an enlarging
axillary mass.
MAMMOGRAPHY: Right axillary
(A) view shows a prominent
ductal and glandular pattern
in the area of the mass in
the axilla. On ultrasound (B),
dilated ducts are noted in the
subcutaneous area. The findings are consistent with accessory breast tissue that is
enlarging secondary to the
pregnancy.
IMPRESSION: Accessory breast in
the axilla, with changes related
to pregnancy.

breast cancer, Jensen et al. (6) found the TDLUs remain
well developed.
The work of Wellings et al. (5) has suggested that the
TDLU is a basic histopathologic unit of breast from which
many benign and malignant lesions arise. Fibroadenomas,
sclerosing adenosis, apocrine cysts, lobular hyperplasia,
and lobular carcinoma in situ are thought to develop in the
lobule itself; ductal hyperplasia and ductal carcinoma in

situ develop in the TDLU. Solitary intraductal papillomas,
epithelial hyperplasia of the larger ducts, and duct ectasia
occur in the main lactiferous ducts (4). Correlative studies
between radiographic and histologic appearances of the
breast parenchyma suggest that small nodular densities on
mammography represent lesions of the terminal duct lobular units and that linear densities are due to periductal
and perilobular fibrosis (7).

BLOOD SUPPLY AND LYMPHATIC
DRAINAGE
The primary arterial supply to the breast is from the perforating branches of the internal mammary and lateral
(text continues on page 5)


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Chapter 1 • Anatomy of the Breast

A.

B.
Figure 1.2
HISTORY: A 50-year-old woman with fullness in the right breast inferiorly.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show heterogeneously dense breasts. In the
right breast at 6 o’clock is a prominent focal area of asymmetric breast tissue (arrow).

Ultrasound showed no focal abnormality. No mass was palpable on clinical examination of
this area.
IMPRESSION: Focal asymmetric breast tissue consistent with accessory breast.
NOTE: Accessory breast tissue is typically located laterally above the nipple line and medially

below the nipple line.

3


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Atlas of Mammography

A.

B.

C.

Figure 1.3
HISTORY: A 55-year-old woman with slight fullness of the inferior aspect of the right breast.
MAMMOGRAPHY: Right CC (A) and MLO (B) views show a focal rounded asymmetry in the inferior aspect of the right breast, located slightly medially (arrow). On a ML (C) view of the lower

aspect of the breast, the very inferior location of the asymmetry in the inframammary area is
noted. On the cleavage view (D), the rounded aspect of the asymmetry is seen.
IMPRESSION: Accessory breast tissue.
NOTE: Accessory breast tissue below the nipple line is located slightly medially, because it develops from the primitive milk streak.

Figure 1.4
HISTORY: A 26-year-old gravida 0, para 0 woman with a history of

ectodermal dysplasia. She had bilateral breast implants placed

during adolescence because of the lack of breast development.
MAMMOGRAPHY: Bilateral MLO views. There are bilateral breast
implants present. There is some dense glandular tissue in the
subareolar area on the left side, but there are only rudimentary
ducts on the right (arrow). The appearance on the right is similar to a normal male breast or a preadolescent female breast.
In the condition of ectodermal dysplasia, there is a lack of normal development of epithelial structures such as nails, teeth,
skin, hair, and sweat glands. Because the breast is a modified
sweat gland and is derived from epithelium, the development
of the breast can be impaired in this condition.
IMPRESSION: Maldevelopment of the breast secondary to ectodermal dysplasia.

D.


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Chapter 1 • Anatomy of the Breast

A.

B.

5

C.

Figure 1.5
HISTORY: Screening mammogram in a patient who is status post augmentation mammoplasty

that was performed for marked asymmetry of breast size.

MAMMOGRAPHY: Bilateral MLO (A) and MLO implant displaced (B) views show that prepectoral
saline implants are present. On the displaced views (B), the left pectoralis major muscle is

present, but no similar structure is seen on the right. There is marked disparity of breast size,
with the right breast being smaller and less glandular than the left, also confirmed on the CC
implant displaced (C) views.
IMPRESSION: Mammary hypoplasia secondary to Poland’s syndrome.
NOTE: Poland’s syndrome is lack of development of the pectoralis major muscle.

thoracic arteries. Minor contributions to the blood come
from the branches of the thoracoacromial, subscapular,
and thoracodorsal arteries (1). Venous drainage is primarily via branches of the internal mammary, intercostal, and
axillary veins. If there is obstruction of the subclavian
vein, collateral drainage produces dilated, tortuous vascular structures, easily visible on mammography (Fig. 1.10).
Lymphatic drainage is via the superficial plexus to the
deep plexus to the axillary and internal mammary lymph
nodes. The low axillary nodes are often visible on mammography, as are small intramammary nodes. It is
unusual to identify on mammography intramammary
nodes in a location other than the superficial region of the
middle- to upper-outer quadrant of the breast.

MUSCULATURE
The breast lays over the musculature of the chest wall:
the pectoralis major and minor muscles. The pectoralis
major muscle has its origins at the anterior medial surface of the clavicle, the sternum, and the aponeurosis of
the external oblique muscle and its insertion on the proximal humerus. The pectoralis major muscle, therefore,
lies obliquely over the chest wall. This angle of obliquity
varies with the body type of the individual. A parameter
for a well-positioned mediolateral oblique (MLO) mammographic view is that the pectoralis major muscle is
visible from the axilla down to the level of the nipple.

Before positioning the patient for the MLO view, the


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Atlas of Mammography

B.

A.
Figure 1.6

HISTORY: A 49-year-old gravida 2, para 2 woman with a history of a plasma cell tumor of the left

lung, treated with pneumonectomy and radiation therapy at age 4 years. The left breast has
been significantly smaller than the right since development. The patient has no history of
breast surgery.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views. Marked asymmetry in the appearance of
the breasts is seen. The left breast is significantly smaller, and there is a paucity of glandular
tissue in comparison with the right. This striking lack of glandular development is presumably related to the lack of development of the breast bud, either from atrophy secondary to the
radiation therapy or from surgery in the left midchest area, which may have involved incidental removal of part of the breast bud.
IMPRESSION: Hypoplasia of the left breast, presumably of iatrogenic origin.

Figure 1.7
Gross anatomy of the normal breast.

technologist must determine the angle of obliquity of the
pectoralis major muscle. She then angles the mammographic receptor and compression device into this position. She is thereby able to compress the breast along the

plane of the pectoralis muscle and to include more
breast tissue. The pectoralis major muscle may be seen
on the craniocaudal (CC) view in about one fourth to
one third patients. Often, the muscle is seen as an area
of density along the posterior aspect of the breast.
Occasionally, the medial aspect of the muscle at the sternal border is prominent and can appear masslike on the
CC view only.
An inconstant muscle that may be present unilaterally
or bilaterally is the sternalis muscle. This is a muscle
band that runs vertically, parallel to the sternum. The
sternalis muscle occurs in 3% to 5% of individuals and is
more frequently observed in women. When present, the
sternalis may be visible on mammography as a triangular or rounded density on the CC view only, and it is
located at the medial, posterior edge of the breast (Figs.
1.11–1.14). It is not evident on the MLO or mediolateral
(ML) views, and ultrasound is normal. If in doubt, a


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Chapter 1 • Anatomy of the Breast

7

Figure 1.8
HISTORY: Patient presenting with a left

serous nipple discharge.
GALACTOGRAM: Left CC (A) and ML (B)

A.

views show filling of the parenchymal
system in the upper-inner quadrant via
the cannulated duct. The normal ductal
structures are seen, ramifying back into
smaller ductal elements and eventually
filling the rounded lobules.
IMPRESSION: Normal ductal anatomy.

B.

Extralobular
terminal duct

computed tomography (CT) scan can be performed and
will demonstrate the sternalis muscle clearly.

Lobule
Intralobular
terminal duct

Terminal
duct lobular
unit

Ductule

Figure 1.9
Classification of the microstructure of the breast (from Wellings

SR, Jensen HM, Marcum RG. An atlas of subgross pathology
of the human breast with special reference to precancerous
lesions. J Natl Cancer Inst 1975;55:231–273 .)

LIFE CYCLE
At birth and in childhood, only rudimentary ducts are
present (Fig. 1.15). At puberty, growth and elongation of
ducts occur, and buds of the future lobules form at the end
of the ducts (4,8). Periductal collagen is deposited, and
mammographically the breast appears very dense and
homogeneous. In the adult, in response to progesterone,
the second stage of glandular development occurs,
namely, the formation of the lobules (8) (Fig. 1.16).
With pregnancy, changes in the parenchyma occur to
make milk secretion possible (8). There is marked
increase in numbers of lobules and an increase in their
size and complexity (4) (Fig. 1.17). In the second and third
trimesters of pregnancy, the terminal ductules expand
into the secreting alveoli (4). Prolactin, in the presence of
insulin, growth hormone, and cortisol, changes the
epithelial cells of the alveoli into a secretory state (1). With


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Atlas of Mammography

A.

B.

Figure 1.10
HISTORY: A 71-year-old woman with a history of diabetes, chronic renal failure, pulmonary

embolism, and thrombophilia.
MAMMOGRAPHY: Bilateral CC (A) and MLO (B) views show circuitous vascular structures

extending into the axillary regions. These are enlarged venous collaterals, likely secondary to
the history of pulmonary embolism and a clot in the superior vena cava.
IMPRESSION: Enlarged venous collaterals.

A.

B.

Figure 1.11
HISTORY: A 51-year-old women for screening mammography.
MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show scattered fibroglandular densities.

There are bilateral dense ovoid masslike densities located far medially at the chest wall
(arrows). The obtuse angle at the chest wall is typical of a muscular structure.
IMPRESSION: Sternalis muscle.


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Chapter 1 • Anatomy of the Breast

A.

B.

C.

D.

E.

Figure 1.12
HISTORY: Screening mammogram.
MAMMOGRAPHY: Bilateral CC views (A) show a focal masslike density in the far medial posterior
aspect of the left breast (arrow). The normal pectoralis major muscle extends obliquely down
the chest wall on the MLO view (B), however, the focal density is not seen. The masslike density is evident on the cleavage view (C). On the rolled CC lateral (D) and medial (E) views, the

density changes shape and appears more obtuse at the chest wall.
IMPRESSION: Sternalis muscle.

9


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Atlas of Mammography

the onset of lactation, the alveoli become maximally
dilated, and milk production occurs. On mammography

(Figs. 1.18 and 1.19), the lactating breast usually appears
extremely dense, and dilated ducts may be seen. However,
in a study of 18 women who were pregnant or lactating,
Swinford et al. (9) found that these patients did not always
have dense breasts. In this study, all seven lactating
women had heterogeneously dense or extensively dense
breasts, yet in 4 of 6 women, the density had not increased
from the prepartum mammogram. After lactation ceases,
the hypertrophied lobules shrink and may disappear. The
breasts of parous women tend to appear more fatty and
radiolucent than those of nulliparous women.
With menopause, there is further involution of the
parenchyma. The terminal lobules disappear, and the
small ducts eventually atrophy. The main ducts are not

A.

greatly affected (4) (Fig. 1.20). The postmenopausal breast
appears more radiolucent (10,11), and only minimal glandular elements are generally seen (Fig. 1.21). However, in
some patients who have marked fibrocystic changes premenopausally or who are nulliparous, persistent dense
parenchyma may be seen postmenopausally (Fig. 1.22).
The effects of endogenous hormones related to the
menstrual cycle have been observed on the histologic
appearance of the normal breast (12). During the first half
of the menstrual cycle, the effect of estrogen is to stimulate breast epithelial proliferation. In the second half of
the cycle, after ovulation, progesterone causes ductal
dilatation and differentiation of the ductular epithelial
cells into secretory cells. In the 3 to 4 days before menses,
edema and enhanced ductular acinar proliferation occur
(1,12,13). Mammography at this time is more difficult

B.

C.

Figure 1.13
HISTORY: Screening mammogram.
MAMMOGRAPHY: Right CC view (A) shows a focal density posteriorly in the medial
aspect of the right breast (arrow) not seen on the MLO (B) view. The density is
more triangular in appearance on the exaggerated CC medial (C) view; no
abnormality was found on ultrasound (D). The location and appearance of this

D.

structure are characteristic of a normal variant, the sternalis muscle.
IMPRESSION: Sternalis muscle.


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Chapter 1 • Anatomy of the Breast

A.

B.

11

C.

E.
Figure 1.14
HISTORY: A 46-year-old patient referred for needle localization of a right breast mass.
MAMMOGRAPHY: Right CC view (A) shows an oval masslike density located at the chest
wall, far posteriorly (arrow). The lesion was not seen on the MLO view (B), however,
it persisted on the spot-compression CC (C) view. On the rolled medial CC view (D),

D.

the area changes shape considerably, becoming more obtuse with the chest wall.
Ultrasound was performed of the entire medial aspect of the breast and was negative. On CT (E), the asymmetry of the parasternal musculature is seen (arrow). There
is an accessory muscle on the right consistent with sternalis muscle and corresponding to the mammographic finding.
IMPRESSION: Right sternalis muscle.


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Atlas of Mammography

Childhood

Puberty

Adult

Lactation

Postmenopausal

Figure 1.15
Changes that the normal breast undergoes during the life cycle.

because the breasts are tender and may appear more
dense. In a study of women aged 40 to 49 years, who were
not on exogenous hormones, White et al. (14) found that
breast parenchyma is less radiographically dense in the
follicular rather than the luteal phase of the menstrual
cycle. Postmenstrually, the edema is reduced, and secretory activity of the epithelium regresses (1,12).
Exogenous hormones may also have an effect on the
mammographic appearance of the breast (Fig. 1.23). An

A.

increase in mammography density has been observed in
10% to 73% of women on combined therapy with estrogen
and progesterone (15–24). Marugg et al. (19) found that
31% of patients treated with combination hormone
replacement therapy (HRT) had an increase in fibroglandular tissue compared with 8.7% of women treated with
estrogens alone, and this difference was statistically significant. Laya et al. (20) found that the increase in density
was more pronounced in women with a lower baseline

B.

Figure 1.16
HISTORY: A 32-year-old gravida 2, para 2 woman with a positive family history of breast cancer,

for screening mammography.
MAMMOGRAPHY: Bilateral MLO (A) and CL (B) views show diffusely dense breast tissue with no

focal abnormalities. This parenchymal pattern is often seen in young patients, and the density
is related to parenchymal and stromal elements.
IMPRESSION: Normal breast, young patient.


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Figure 1.17
HISTOPATHOLOGY: High power section of a lactating breast: the

lobules are distended and filled with an eosinophilic material;
secretory vacuoles are noted in the cells lining the glands.

A.

B.

Figure 1.18
HISTORY: A 32-year-old lactating woman, with a family history of pre-

C.

menopausal breast cancer in the grandmother, presents with a palpable
right subareolar mass.
MAMMOGRAPHY: Bilateral CC (A) views show marked increase in density bilaterally with ductal dilatation. Comparison with a prior study (B) shows the

parenchymal changes related to lactation. Ultrasound of the subareolar area
(C) shows fluid-filled dilated ducts.
IMPRESSION: Lactational changes, dilated ducts.